We can't yet know the details the NHS information and technology strategies expected to emerge from the Department of Health later this year. However we can be pretty sure of the direction of travel: away from the already disowned "rip and replace" philosophy of the old National Programme for IT in England and towards a world in which healthcare teams create electronic patient records by interlinking existing specialist systems, based wherever possible on open standards and software. And with little or no new central funding to make that happen.

For a glimpse today of how the future may look, a good place to start is Leeds Teaching Hospitals, one of England's largest trusts. It has developed a web portal that allows accident and emergency teams to call up clinical and administrative data from specialist systems, all done with open source. Dr Tony Shannon, the trust's clinical lead for informatics, believes the trust's "integration and standards-based" approach should prove cheaper than that promoted by the big systems vendors.

Shannon is a member of a still-rare breed - clinicians with real depth and breadth of experience in healthcare informatics. After qualifying in his native Ireland, he specialised in emergency medicine and developed his interest in informatics through a fellowship in Washington DC and a masters degree in IT management. He spent four years as a clinical lead with the NHS IT agency Connecting for Health, working with the north eastern cluster on the immense technical and cultural challenges of implementing new systems prescribed through the NHS national programme.

The experience left Dr Shannon wary of top-down approaches to the NHS's information needs. The national programme, he says, was flawed from the start, with the assumption that the NHS could be run with a small number of approved "rip and replace" systems. "The assumption at the time was that the solutions were out there, we just needed better programme management," he says. "They didn't understand that healthcare is a complex adaptive system, and needs to be treated more as an eco-system than as a machine."

Opening up

Dr Shannon has also been a leading figure in the Open EHR project, an international effort to build an electronic health record based on modular open source components, filling what he says is a gap between what systems vendors are offering and what is needed for clinical care.

After leaving CfH 18 months ago, Shannon has had a chance to put some of his ideas into action at Leeds. "There's no appetite here for rip and replace LSP systems," he says, referring to the local service providers used by Connecting for Health to install new EHRs. Instead, he has won initial support for a "portal and integration project", starting in the casualty department. The idea is to build a web based open source portal functioning as a single front end to the collection of systems used throughout the hospital.

Getting backing for open source "took some effort", he concedes. However after beginning in earnest only last August, the Leeds project has now gone live in the emergency department in what Dr Shannon calls a "first phase test". He adds: "Considering we built it from scratch in nine months, that's not bad."

The initial aim is to hook five systems into the portal. So far, three have gone live; the patient administration system, an in-house oncology system and a clinical information system. Next will be the Ascribe information system and an Emis system used on a respiratory ward. That's still only a part of the total inventory: "We've got 200 existing systems in the trust - we're a fairly typical large organisation," Shannon says.

One more lesson from experience is not to make any grand claims that the EHR will cut costs. "I've said from the start that the evidence behind healthcare IT savings is mixed," says Dr Shannon, "I've never tried to pretend that there are cost or time savings." Rather, "We're trying to demonstrate that we can improve the quality of care and reduce risk, improve the quality of the clinical encounter by having information available." For all this caution, Dr Shannon expects that the switch to open source will at least cut the cost of software licensing.

As for the next step in roll-out, he says: "We need to get agreement from the informatics board." Dr Shannon is careful to point out that the portal should not be seen as a one-off, but will comply with standards such as the Common User Interface to enable wider adoption when the time is right.

But can Dr Shannon be confident that the political wind is now blowing in the right way? He is quietly optimistic, but observes "a disconnect" between the Cabinet Office strategic open source message and the current NHS position. "We don't have as much backing as we'd like."